Fitness For Duty Template – Fill Out and Use This PDF

Fitness for Duty Certification

Form to be completed by health care provider. An employee on a medical leave under the Family and Medical Leave Act (FMLA) must present this Fitness for Duty Certification to their supervisor prior to returning to work.

The Family and Medical Leave Act (FMLA) guidelines are applied to employees who are on paid or unpaid leave. This form is for return to work purposes of medical leave of absence due to an illness or injury, whether work or non-work related. Because employees are valuable resources, health care providers should assist employees in returning to work as soon as possible.

Health Care Professionals: Your patient has three return to work options.

Full Release. The patient has no work restrictions. They can return to his or her prior position because you, the health care provider certify, that he or she can perform the essential functions of their job.

Modified Duty. The patient has some work restrictions. Work restrictions must be specifically notated on page two of this form. Each modified duty work restriction request will be reviewed carefully to determine if the employee can perform the essential functions of the job and return to work.

Not Released. The patient is not released to work in any capacity due to physical or behavioral limitations.

Gina Provision

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Submission

The Fitness for Duty Certification can be submitted confidentially to:

Marquette University Human Resources, Attn: FMLA

PO Box 1881, Straz Tower, Room 185

Milwaukee, WI 53201-1881

Fax: (414) 288-7425 | Phone: (414) 288-7496

June 2011

Fitness for Duty Certification

3.Please check the status of the employee’s release for duty

Full, unrestricted duty effective __________________________

Modified duty effective ________________ and next evaluation date ________________

Not released for any type of duty. Next evaluation date will be ________________

4. Physical Evaluation

Sedentary-Lifting 0 to 10 pounds

Light-Lifting 10 to 20 pounds

Moderate-Lifting 20 to 50 pounds

Heavy-Lifting 50 to 100 pounds

Pulling/Pushing, Carrying

Reaching or working above shoulder

Walking

Standing

Stooping

Kneeling

Repeated Bending

Climbing

Operating a motor vehicle

Finger Manipulation (typing)

Pain (frequency, degree, signs)

5. Behavioral Evaluation

Understanding

Remembering

Sustained concentration

Follow-through on instructions

Decision making

Receiving supervision

Relating to co-workers and students

6.Other Restrictions, Considerations, or Notes

_____________________________________________________________________________________

_____________________________________________________________________________________

I hereby certify that the facts in this document are true and correct.